__________ fluids are used to correct fluid, electrolyte, and acid-base imbalances by moving water out of the bodys cells and into the blood stream.

Hypertonic

*parenteral nutrition solutions are also hypertonic

Instead of moving water out of the cells, ______ infusates move water into cells to expand them.

Hypotonic

*patients receiving either hypertonic or hypotonic fluids are at arisk for phlebitis and infiltration

the inflammation of a vein caused by mechanical, chemical or bacterial irritation.

Phlebitis

_____ occurs when IV solution leaks into the tissues around the vein.

Infiltration

The pH of IV solutions measures the acidity and alkalinity and usually ranges from:

3.5 and 6.2.

a blood clot in the vein is called

thrombosis

*extremes of both osmolarity and pH can cause vein damage, thus, fluids and meds with a pH value of less than 5 and more than 9 and with an osmolarity of more than 600 mOsm/L are best infused in the central circulation where greater blood flow provides adequate hemodilution.

*TPN solutions have an osmolarity greater than 1400 mOsm/L and should NOT be infused in peripheral circulation because it can damage blood cells and the endothelial lining of veins.

Venous irritants that have a pH less than 5:

amiodarone (Cardarone)

vancomycin (Vancocin)

ciproflaxacin (Cipro I.V.)

Drugs with vasoconstrictive action:

Dopamine

chemotherapeutic agens ie: vinblastine

*vescicants that cause exstravasation which results in severe tissue damage as manifested by blistering, tissue sloughing, or necrosis from infiltration into the surrounding tissues.

Nursing Safety Priority:

Monitor the IV insertion site carefully for early manifestations of infiltration, including swelling, coolness, or redness. If any of these symptoms are present, discontinue the drug immediately and notify the infusion therapy team, if available. If an infusion specialist is not available, plan to remove the IV catheter and consider central line placement.

The ISBT system (International Society of Blood Transfusion) includes 4 components theat must be present on the blood label both in bar code and in eye-readable format.

a unique facility identifier

the lot number relating to the donor

the product code

the ABO group and Rh type of the donor

An acute hemolytic transfusion reaction caused by an incompatible blood transfusion is a ____.

sentinal event

IV administration requires several things:

knowledge of appropriate dilution

rate of infusion

pH and osmolarity

compatibility with other IV meds

appropriate site

potential for vesican effects

drug indications

proper dosage

contraindications

precautions

One major goal of the TJC is :

improving the safety of high alert drugs. ie: concentrated electrolyte solutions (potassium, chloride), which require restricted access, prominent warnings about the concentration, and storage in a secured location

Nursing Safety Alert:

Be sure to check for the accuracy and completeness of the treatment prescription. ie of incomplete prescription is "5% dextrose in water to keep the vein open". This statement doesn't specify the rate of infusion and is not considered complete

a plastic tube placed in a blood vessel to deliver fluids and medications is called a

vascular access device or infusion catheter

Seven major types of infusion catheters are:

short perifpher catheters

midline caths

PICC

Nontunneled percutaneous central venous access cath

tunneled caths

implanted ports

hemodialysis cath

Topical anethesthetic agents such as ____ can be used to decrease patient discomfort during insertion.

intradermal lidocaine 1%

__________ catheters are the most commonly used vascular access devices used for peripheral IV therapy

short peripheral cath

*usually inserted into superficial veins fo the dorsal surface of the hand and the forearm using sterile technique. also the jugular vein in emergent situations.

*avoid use of veins in lower extremities in adults because of increased risk for deep vein thrombosis and infiltration

*range in length from 3/4 inch to 1 1/4 inch with gauge sizes from 26 gauge (the smallest) to 14 gauge (large bore)

apply povidone-iodine to the skin and allow to dry for at least two minutes

Common IV sites of the inner arm:

Cephalic vein

axillary vein

brachial vein

basilic vein

median cephalic vein

radial vein

median vein

median basilic

ulnar vein

A patient is in the hospital for his first chemo therapy treament forlung cancer. Which IV access methods are appropriate for this patient? (Select all that apply)

a. Peripheral access

b. PICC

c. Dialysis cath

d. tunneled central venous cath

e. implanted port

answer: b, d, e

______ can be anywhere from three to eight inches long and double or single lumen

Midline catheters

*inserted through veins of the upper arm; most often medial antecubital vein if done without ultrasound guidance

*with ultrasound guide deeper veins can be accessed; basilic preferred over cephalic because of its larger diameter and straighter path

Midline caths can be use when:

skin integrity or limited peripheral veins make it difficult to maintain a short peripheral catheter

fluids for hydration

Longer than six days and up to 4 weeks of therapy such as: antibiotics, heparin infusions for deep vein thrombosis, bronchodilators such as aminophylline and steroids

Drugs that cause severe tissue damange if they escape into the subcutaneous tissue (extravasation)

Vescicant meds

The DO NOTS:(midline cath)

do not infuse parenteral nutrition formulas, including those with low concentrations of dextrose and all solutions that have an osmolarity greater than 600 mOsm/L

Do not draw blood from midline catheters routinely

Do not place in extremities affected by mastectomy with lymphedema, paralysis or dialysis grafts and fistulas

Do Not administer incompatible drugs simultaneously administered through both lumens when using and double lumen because the blood flow rate in the axillary vein is not high enough to ensure adequate hemodilution and prevention of drug interaction in the vein.

In ____ ______ ____ the vascular access device is placed inthe central circulation, specifically within the superior vena cava near its junction with the right atrium.

Central IV therapy

Blood flow in the SVC is approximately:

2 L/min

All central vascular devices require confirmation of placement in the vein by:

radiography

types of CVADs:

PICC

Nontunneled percutaneous central venous catheters (CVCs)

Tunnelled Central Venous Catheters

Implanted cath

hemodialysis cath

A long catheter inserted through a vein of the antecubital fossa or the middle of the upper arm

PICC: periperally inserted central catheter

In adults, the PICC legth ranges from:

18 to 29 inches with the tip residing in teh superior vena cava; placement of the tip in veins distal to the SVC is avoided due to higher rates of thrombosis.

* the basilic vein is the preferred site for insertion of the PICC; the cephalic vein can be used if necessary

______ technique is used for insertion to reduce the risk for cath related bloodstream infections.

sterile technique

*before the cath can be used for infusion, a chest xray indicating that the tip resides inthe lower SVC is required when the catheter is not placed under fluoroscopy

What lumens are PICCs available in?

single

dual

triple

PICCs are available as:

Groshong valve and pressure activated safety valve (PASV)

Power PICCs; which can be used for contrast inujectino at a maximum of 5 ml/sec and a max pressure of 300 psi

Most common complications from PICC lines include:

phlebitis

thrombophlebitis

CR-BSIs (catheter related blood stream infections)

A patient has a PICC inserted and is ordered to received IV cisplatin (Platinol). the drug has infiltrated into the tissue and redness is observed in the right lower side of the neck. What interventions, in order of priority, will the nurse perform?

a. Apply cold compresses to the site of swelling

b. Stop infusion and disconnect the IV line from the admin set.

c. Aspirate the drug from the IV access device

d. Monitor the patient and document.

Answer: B, C, A, then D

The nurse is preparing to give a patient IV drug therapy. What information does the nurse need before administering the drug? (Select all that apply)

a. indications, contraindications, precautions for IV therapy

b. appropriate dilution, pH and osmolarity of solution

c. rate of infusion and dosage

d. generic, chemical, brand name of the drug

e. compatibility with other IV meds

f. percentage of adverse events for the drug

g. specifics of monitoring because of immediate effect

answer: A, B, C, E, G

The charge nurse is reviewing IV therapy orders. what information is included in each order? (All that apply)

a. specific type of solution

b. rate

c. specific drug dose to be added to solution

d. method for diluting drugs for the solution

e. specific type of administration equipment

answer: A, B, C

The nurse must insert a short peripheral IV catheter. In order to decrease teh risk of deep vein thrombosis or phlebitis, which vein does the nurse choose for the infusion site?

a. Hand

b. foot

c. forearm

d. antecubital

answer: forearm

Which items does the nurse include in the documentation after completing the insertion of a PICC?

a. type of dressing applied

b. response of the family to IV Access

c. type of IV access device used

d. how long it took to place

e. location and vein used for insertion

anser: A, C, E

A patient has a PICC placed by an advanced practice nurse at the bedside. Before using the cath, how is it's placement verified?

A chest x-ray is taken which shows the catheter tip in the lower superior vena cava

A patient requires a 2 month course of antibiotics to treat a resistant infection. Which device is chosen for this therapy?

a PICC

The nurse is attempting to remove a PICC line and feels resistance. What techniques does the nurse use first to attempt to resolve this problem?

Use simple distraction techniques and deep breathing

PICCs can be use for blood sampling; however, a lumen size of ____ or larger are recommended